PDF herunterladen
Semin Respir Crit Care Med 2022; 43(02): 248-254
DOI: 10.1055/s-0041-1740246
Review Article

HAP and VAP after Guidelines

Paul-Henri Wicky
1   Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat Hospital, Paris Diderot University, Paris, France
,
Ignacio Martin-Loeches
2   Department of Anaesthesia and Critical Care Medicine, St. James's Hospital, Dublin, Ireland
3   Multidisciplinary Intensive Care Research Organization (MICRO), St James's Hospital, Dublin, Ireland
,
Jean-François Timsit
1   Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat Hospital, Paris Diderot University, Paris, France
4   UMR 1137, IAME, Université Paris Diderot, Paris, France
› Institutsangaben
› Weitere Informationen
    Lizenzen und Reprints

Abstract

Nosocomial pneumonia is associated with worsened prognosis when diagnosed in intensive care unit (ICU), ranging from 12 to 48% mortality. The incidence rate of ventilation-acquired pneumonia tends to decrease below 15/1,000 intubation-day. Still, international guidelines are heterogeneous about diagnostic criteria because of inaccuracy of available methods. New entities have thus emerged concerning lower respiratory tract infection, namely ventilation-acquired tracheobronchitis (VAT), or ICU-acquired pneumonia (ICUAP), eventually requiring invasive ventilation (v-ICUAP), according to the type of ventilation support. The potential discrepancy with non-invasive methods could finally lead to underdiagnosis in almost two-thirds of non-intubated patients. Delayed diagnostic could explain in part the 2-fold increase in mortality of penumonia when invasive ventilation is initiated. Here we discuss the rationale underlying this new classification.

Many situations can lead to misdiagnosis, even more when the invasive mechanical ventilation is initiated. The chest radiography lacks sntivity and specificity for diagnosing pneumonia. The place of chest computed tomography and lung ultrasonography for routine diagnostic of new plumonary infiltrate remain to be evaluated.

Microbiological methods used to confirm the diagnostic can be heterogeneous. The development of molecular diagnostic tools may improve the adequacy of antimicrobial therapies of ventilated patients with pneumonia, but we need to further assess its impact in non-ventilated pneumonia.

In this review we introduce distinction between hospital-acquired pneumonia according to the localization in the hospital and the oxygenation/ventilation mode. A clarification of definition is the first step to develop more accurate diagnostic strategies and to improve the patients' prognosis.

Keywords

hospital-acquired pneumonia - ventilator-associated pneumonia - ventilator-associated tracheobronchitis - ventilator-associated lower respiratory tract infection


Publikationsverlauf

Artikel online veröffentlicht:
18. Januar 2022

© 2022. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Underlying Cause of Death. 1999–2019 results form. Accessed September 12, 2021 at: https://wonder.cdc.gov/controller/datarequest/D76;jsessionid=AE034F41D46EC22B2696BE80DB85
    PubMedGoogle Scholar
  • 2 De Pascale G, Ranzani OT, Nseir S. et al. Intensive care unit patients with lower respiratory tract nosocomial infections: the ENIRRIs project. ERJ Open Res 2017; 3 (04) 00092-02017
    CrossrefPubMedGoogle Scholar
  • 3 Martin-Loeches I, Zampieri F, Povoa P. et al. Respiratory research networks in Europe and beyond: aims, achievements and aspirations for the 21st century. Breathe (Sheff) 2017; 13 (03) 209-215
    CrossrefPubMedGoogle Scholar
  • 4 Ibn Saied W, Mourvillier B, Cohen Y. et al; OUTCOMEREA Study Group. A comparison of the mortality risk associated with ventilator-acquired bacterial pneumonia and nonventilator ICU-acquired bacterial pneumonia. Crit Care Med 2019; 47 (03) 345-352
    CrossrefPubMedGoogle Scholar
  • 5 Esperatti M, Ferrer M, Giunta V. et al. Validation of predictors of adverse outcomes in hospital-acquired pneumonia in the ICU. Crit Care Med 2013; 41 (09) 2151-2161
    CrossrefPubMedGoogle Scholar
  • 6 Micek ST, Chew B, Hampton N, Kollef MH. A case-control study assessing the impact of nonventilated hospital-acquired pneumonia on patient outcomes. Chest 2016; 150 (05) 1008-1014
    CrossrefPubMedGoogle Scholar
  • 7 Vallecoccia MS, Dominedò C, Cutuli SL, Martin-Loeches I, Torres A, De Pascale G. Is ventilated hospital-acquired pneumonia a worse entity than ventilator-associated pneumonia?. Eur Respir Rev 2020; 29 (157) 200023
    CrossrefPubMedGoogle Scholar
  • 8 Prin M, Wunsch H. International comparisons of intensive care: informing outcomes and improving standards. Curr Opin Crit Care 2012; 18 (06) 700-706
    CrossrefPubMedGoogle Scholar
  • 9 Vincent J-L, Sakr Y, Singer M. et al; EPIC III Investigators. Prevalence and outcomes of infection among patients in intensive care units in 2017. JAMA 2020; 323 (15) 1478-1487
    CrossrefPubMedGoogle Scholar
  • 10 Marini JJ, DeBacker D, Gattinoni L. et al. Thinking forward: promising but unproven ideas for future intensive care. Crit Care 2019; 23 (Suppl. 01) 197
    CrossrefPubMedGoogle Scholar
  • 11 Rodríguez A, Póvoa P, Nseir S, Salluh J, Curcio D, Martin-Loeches I. TAVeM group investigators. Incidence and diagnosis of ventilator-associated tracheobronchitis in the intensive care unit: an international online survey. Crit Care 2014; 18 (01) R32
    CrossrefPubMedGoogle Scholar
  • 12 Nseir S, Martin-Loeches I, Makris D. et al. Impact of appropriate antimicrobial treatment on transition from ventilator-associated tracheobronchitis to ventilator-associated pneumonia. Crit Care 2014; 18 (03) R129
    CrossrefPubMedGoogle Scholar
  • 13 Martin-Loeches I, Povoa P, Rodríguez A. et al; TAVeM study. Incidence and prognosis of ventilator-associated tracheobronchitis (TAVeM): a multicentre, prospective, observational study. Lancet Respir Med 2015; 3 (11) 859-868
    CrossrefPubMedGoogle Scholar
  • 14 Pássaro L, Harbarth S, Landelle C. Prevention of hospital-acquired pneumonia in non-ventilated adult patients: a narrative review. Antimicrob Resist Infect Control 2016; 5: 43
    CrossrefPubMedGoogle Scholar
  • 15 Weiss E, Essaied W, Adrie C, Zahar J-R, Timsit J-F. Treatment of severe hospital-acquired and ventilator-associated pneumonia: a systematic review of inclusion and judgment criteria used in randomized controlled trials. Crit Care 2017; 21 (01) 162
    CrossrefPubMedGoogle Scholar
  • 16 de Kraker MEA, Sommer H, de Velde F. et al; COMBACTE-NET Consortium. Optimizing the design and analysis of clinical trials for antibacterials against multidrug-resistant organisms: a white paper from COMBACTE's STAT-Net. Clin Infect Dis 2018; 67 (12) 1922-1931
    PubMedGoogle Scholar
  • 17 Timsit J-F, de Kraker MEA, Sommer H. et al; COMBACTE-NET consortium. Appropriate endpoints for evaluation of new antibiotic therapies for severe infections: a perspective from COMBACTE's STAT-Net. Intensive Care Med 2017; 43 (07) 1002-1012
    CrossrefPubMedGoogle Scholar
  • 18 Saied W, Martin-Loeches I, Timsit J-F. What is new in non-ventilated ICU-acquired pneumonia?. Intensive Care Med 2020; 46 (03) 488-491
    CrossrefPubMedGoogle Scholar
  • 19 Ferrer M, Torres A. Epidemiology of ICU-acquired pneumonia. Curr Opin Crit Care 2018; 24 (05) 325-331
    CrossrefPubMedGoogle Scholar
  • 20 Martin-Loeches I, Metersky M, Kalil A, Pezzani MD, Torres A. Strategies for implementation of a multidisciplinary approach to the treatment of nosocomial infections in critically ill patients. Expert Rev Anti Infect Ther 2021; 19 (06) 759-767
    CrossrefPubMedGoogle Scholar
  • 21 Zaragoza R, Vidal-Cortés P, Aguilar G. et al. Update of the treatment of nosocomial pneumonia in the ICU. Crit Care 2020; 24 (01) 383
    CrossrefPubMedGoogle Scholar
  • 22 Timsit J-F, Huntington JA, Wunderink RG. et al. Ceftolozane/tazobactam versus meropenem in patients with ventilated hospital-acquired bacterial pneumonia: subset analysis of the ASPECT-NP randomized, controlled phase 3 trial. Crit Care 2021; 25 (01) 290
    CrossrefPubMedGoogle Scholar
  • 23 Weiss E, Zahar J-R, Alder J. et al. Elaboration of consensus clinical endpoints to evaluate antimicrobial treatment efficacy in future hospital-acquired/ventilator-associated bacterial pneumonia clinical trials. Clin Infect Dis 2019; 69 (11) 1912-1918
    CrossrefPubMedGoogle Scholar
  • 24 Pouly O, Lecailtel S, Six S. et al. Accuracy of ventilator-associated events for the diagnosis of ventilator-associated lower respiratory tract infections. Ann Intensive Care 2020; 10 (01) 6
    CrossrefPubMedGoogle Scholar
  • 25 Fan Y, Gao F, Wu Y, Zhang J, Zhu M, Xiong L. Does ventilator-associated event surveillance detect ventilator-associated pneumonia in intensive care units? A systematic review and meta-analysis. Crit Care 2016; 20 (01) 338
    CrossrefPubMedGoogle Scholar
  • 26 Martin-Loeches I, Rodriguez AH, Torres A. New guidelines for hospital-acquired pneumonia/ventilator-associated pneumonia: USA vs. Europe. Curr Opin Crit Care 2018; 24 (05) 347-352
    CrossrefPubMedGoogle Scholar
  • 27 Torres A, Niederman MS, Chastre J. et al. Summary of the international clinical guidelines for the management of hospital-acquired and ventilator-acquired pneumonia. ERJ Open Res 2018; 4 (02) 00028-2018
    CrossrefPubMedGoogle Scholar
  • 28 Ferrer M, Sequeira T, Cilloniz C. et al. Ventilator-associated pneumonia and PaO2/FIO2 diagnostic accuracy: changing the paradigm?. J Clin Med 2019; 8 (08) E1217
    CrossrefPubMedGoogle Scholar
  • 29 Greene LR. Non-ventilator health care-associated pneumonia (NV-HAP): putting it all together. Am J Infect Control 2020; 48 (5S): A36-A38
    CrossrefPubMedGoogle Scholar
  • 30 Martin-Loeches I, Torres A, Povoa P. et al; TAVeM study Group. The association of cardiovascular failure with treatment for ventilator-associated lower respiratory tract infection. Intensive Care Med 2019; 45 (12) 1753-1762
    CrossrefPubMedGoogle Scholar
  • 31 Prendki V, Scheffler M, Huttner B. et al. Low-dose computed tomography for the diagnosis of pneumonia in elderly patients: a prospective, interventional cohort study. Eur Respir J 2018; 51 (05) 1702375
    CrossrefPubMedGoogle Scholar
  • 32 Garin N, Marti C, Carballo S. et al. Rational use of CT-scan for the diagnosis of pneumonia: comparative accuracy of different strategies. J Clin Med 2019; 8 (04) E514
    CrossrefPubMedGoogle Scholar
  • 33 Bouhemad B, Dransart-Rayé O, Mojoli F, Mongodi S. Lung ultrasound for diagnosis and monitoring of ventilator-associated pneumonia. Ann Transl Med 2018; 6 (21) 418
    CrossrefPubMedGoogle Scholar
  • 34 Pradhan S, Shrestha PS, Shrestha GS, Marhatta MN. Clinical impact of lung ultrasound monitoring for diagnosis of ventilator associated pneumonia: a diagnostic randomized controlled trial. J Crit Care 2020; 58: 65-71
    CrossrefPubMedGoogle Scholar
  • 35 Koulenti D, Zhang Y, Fragkou PC. Nosocomial pneumonia diagnosis revisited. Curr Opin Crit Care 2020; 26 (05) 442-449
    CrossrefPubMedGoogle Scholar
  • 36 Luyt C-E, Bouadma L, Morris AC. et al. Pulmonary infections complicating ARDS. Intensive Care Med 2020; 46 (12) 2168-2183
    CrossrefPubMedGoogle Scholar
  • 37 Schmidt M, Bréchot N, Hariri S. et al. Nosocomial infections in adult cardiogenic shock patients supported by venoarterial extracorporeal membrane oxygenation. Clin Infect Dis 2012; 55 (12) 1633-1641
    CrossrefPubMedGoogle Scholar
  • 38 Franchineau G, Luyt CE, Combes A, Schmidt M. Ventilator-associated pneumonia in extracorporeal membrane oxygenation-assisted patients. Ann Transl Med 2018; 6 (21) 427
    CrossrefPubMedGoogle Scholar
  • 39 Luyt C-E, Sahnoun T, Gautier M. et al. Ventilator-associated pneumonia in patients with SARS-CoV-2-associated acute respiratory distress syndrome requiring ECMO: a retrospective cohort study. Ann Intensive Care 2020; 10 (01) 158
    CrossrefPubMedGoogle Scholar
  • 40 Bouglé A, Bombled C, Margetis D. et al. Ventilator-associated pneumonia in patients assisted by veno-arterial extracorporeal membrane oxygenation support: epidemiology and risk factors of treatment failure. PLoS One 2018; 13 (04) e0194976
    CrossrefPubMedGoogle Scholar
  • 41 Aubron C, Cheng AC, Pilcher D. et al. Infections acquired by adults who receive extracorporeal membrane oxygenation: risk factors and outcome. Infect Control Hosp Epidemiol 2013; 34 (01) 24-30
    CrossrefPubMedGoogle Scholar
  • 42 Kenaa B, Richert ME, Claeys KC. et al. Ventilator-associated pneumonia: diagnostic test stewardship and relevance of culturing practices. Curr Infect Dis Rep 2019; 21 (12) 50
    CrossrefPubMedGoogle Scholar
  • 43 Fernando SM, Tran A, Cheng W. et al. Diagnosis of ventilator-associated pneumonia in critically ill adult patients-a systematic review and meta-analysis. Intensive Care Med 2020; 46 (06) 1170-1179
    CrossrefPubMedGoogle Scholar
  • 44 Al-Omari B, McMeekin P, Allen AJ. et al. Systematic review of studies investigating ventilator associated pneumonia diagnostics in intensive care. BMC Pulm Med 2021; 21 (01) 196
    CrossrefPubMedGoogle Scholar
  • 45 Berton DC, Kalil AC, Teixeira PJZ. Quantitative versus qualitative cultures of respiratory secretions for clinical outcomes in patients with ventilator-associated pneumonia. Cochrane Database Syst Rev 2012; 1: CD006482
    PubMedGoogle Scholar
  • 46 Ranzani OT, Senussi T, Idone F. et al. Invasive and non-invasive diagnostic approaches for microbiological diagnosis of hospital-acquired pneumonia. Crit Care 2019; 23 (01) 51
    CrossrefPubMedGoogle Scholar
  • 47 Xu E, Pérez-Torres D, Fragkou PC, Zahar J-R, Koulenti D. Nosocomial pneumonia in the era of multidrug-resistance: updates in diagnosis and management. Microorganisms 2021; 9 (03) 534
    CrossrefPubMedGoogle Scholar
  • 48 Kalil AC, Metersky ML, Klompas M. et al. Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis 2016; 63 (05) e61-e111
    CrossrefPubMedGoogle Scholar
  • 49 Torres A, Niederman MS, Chastre J. et al. International ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia: guidelines for the management of hospital-acquired pneumonia (HAP)/ventilator-associated pneumonia (VAP) of the European Respiratory Society (ERS), European Society of Intensive Care Medicine (ESICM), European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and Asociación Latinoamericana del Tórax (ALAT). Eur Respir J 2017; 50 (03) 1700582
    CrossrefPubMedGoogle Scholar
  • 50 Luyt C-E, Hékimian G, Bonnet I. et al. Usefulness of point-of-care multiplex PCR to rapidly identify pathogens responsible for ventilator-associated pneumonia and their resistance to antibiotics: an observational study. Crit Care 2020; 24 (01) 378
    CrossrefPubMedGoogle Scholar
  • 51 Loubet P, Voiriot G, Houhou-Fidouh N. et al. Impact of respiratory viruses in hospital-acquired pneumonia in the intensive care unit: a single-center retrospective study. J Clin Virol 2017; 91: 52-57
    CrossrefPubMedGoogle Scholar
  • 52 Kollef MH, Burnham CD. Ventilator-associated pneumonia: the role of emerging diagnostic technologies. Semin Respir Crit Care Med 2017; 38 (03) 253-263
    Artikel in Thieme ConnectPubMedGoogle Scholar
  • 53 Liapikou A, Cillóniz C, Torres A. Emerging strategies for the noninvasive diagnosis of nosocomial pneumonia. Expert Rev Anti Infect Ther 2019; 17 (07) 523-533
    CrossrefPubMedGoogle Scholar
  • 54 Peiffer-Smadja N, Bouadma L, Mathy V. et al. Performance and impact of a multiplex PCR in ICU patients with ventilator-associated pneumonia or ventilated hospital-acquired pneumonia. Crit Care 2020; 24 (01) 366
    CrossrefPubMedGoogle Scholar
  • 55 Monard C, Pehlivan J, Auger G. et al; ADAPT study group. Multicenter evaluation of a syndromic rapid multiplex PCR test for early adaptation of antimicrobial therapy in adult patients with pneumonia. Crit Care 2020; 24 (01) 434
    CrossrefPubMedGoogle Scholar
  • 56 Maes M, Higginson E, Pereira-Dias J. et al. Ventilator-associated pneumonia in critically ill patients with COVID-19. Crit Care 2021; 25 (01) 25
    CrossrefPubMedGoogle Scholar
  • 57 Trotter AJ, Aydin A, Strinden MJ, O'Grady J. Recent and emerging technologies for the rapid diagnosis of infection and antimicrobial resistance. Curr Opin Microbiol 2019; 51: 39-45
    CrossrefPubMedGoogle Scholar
  • 58 Gastli N, Loubinoux J, Daragon M. et al; French FA-PP study group. Multicentric evaluation of BioFire FilmArray pneumonia panel for rapid bacteriological documentation of pneumonia. Clin Microbiol Infect 2021; 27 (09) 1308-1314
    CrossrefPubMedGoogle Scholar